Curtis v. Aetna Life Ins. Co.

DENNIS E. CURTIS,on his own behalf and on behalf of all others similarly situated, Plaintiffs, v. AETNA LIFE INSURANCE COMPANY, Defendant.

No. 3:19-cv-01579

UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT

March 18, 2021

RULING ON MOTION TO DISMISS

Plaintiff Dennis E. Curtis ("Curtis"), on his own behalf and on behalf of all others similarly situated, brings this action against Aetna Life Insurance Company ("Aetna") alleging that Aetna has violated the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001 et seq., by failing to administer Curtis's and the putative class members' claims for benefits under their ERISA group medical benefits plans in accordance with the plans' provisions. Compl., ECF No. 28. Specifically, Curtis alleges that Aetna has violated ERISA by denying benefits to plan members based upon definitions of "medically necessary" contained in a series of internal Aetna Clinical Policy Bulletins that are not a part of, or incorporated in, any of the ERISA plans and that modify and limit, to plan members' detriment, the plans' definition of "medically necessary." Id.; ECF No. 38 at 6-7. Aetna filed a motion to dismiss, seeking to dismiss the complaint in its entirety. ECF No. 33. For the reasons set forth herein, the defendant's motion to dismiss is GRANTED.

I. BACKGROUND

The following facts are drawn from Curtis's operative complaint and the exhibits attached to Aetna's motion, which include the relevant ERISA plan and the principal Clinical Policy Bulletin discussed in the complaint.¹ These facts are accepted as true for the purpose of this motion.

Curtis, a resident of the State of Connecticut, is a beneficiary of a group medical benefits plan established by his wife's employer, Yale University ("Yale"), for its employees and their beneficiaries. The plan (the "Yale Plan") is an employee benefit plan subject to ERISA. Claims administration for the Yale Plan is provided by Aetna, a Connecticut corporation that performs claims administration services for ERISA plans funded by third party employers such as Yale, as well as for ERISA plans that Aetna or its affiliated companies directly insure. ECF No. 28 ¶¶ 1, 9-13.²

The Yale Plan, as is customary in all of the ERISA group medical benefits plans administered by Aetna, limits coverage to "medically necessary" health care expenses. The Yale Plan contains a standard definition of "medically necessary" that is substantially identical to the definition of "medically necessary" in the other ERISA plans administered by Aetna. Id. ¶¶ 2, 16. Aetna maintains a series of internal Aetna Clinical Policy Bulletins ("CPBs") that are not a part of, or incorporated in, any of the Plans and that modify and limit the Plans' definition of "medically necessary." Id. ¶ 3. The CPBs purport to set forth Aetna's view of when medicalservices for physical therapy and other forms of rehabilitative therapy should be deemed medically necessary. Id.

Aetna denies benefits for such therapy services based upon the definitions of medically necessary in the CPBs, even though the services qualify as medically necessary pursuant to the definition of that term set forth in the Plans. Id. Specifically, Aetna has denied coverage for physical therapy services prescribed by Curtis's and other covered members' physicians, based on Aetna's CPB #325, which restricts a finding that physical therapy services are medically necessary to circumstances in which such services will "improve significantly" the patient's condition within a 30-day period and excludes physical therapy services necessary to preserve or prevent deterioration of physical function or as to which the time for expected improvement cannot be predicted. These limitations are not contained in the Plans' definition of medically necessary and are contrary to accepted medical standards for when physical therapy is medically warranted. Aetna has similarly denied benefits to covered plan members for occupational, speech, cognitive rehabilitation and other forms of therapy as not medically necessary based upon provisions of other CPBs that likewise either add requirements to or are not consistent with the plain words of the Plans' definition of "medically necessary." Id. ¶ 4.

A. Dennis E. Curtis

In July 2016, Curtis began receiving physical therapy treatment, pursuant to his treating physicians' orders and prescriptions, to treat balance, strength and mobility issues caused by neurological and other conditions and surgical procedures. Aetna initially approved coverage and benefits for Curtis's physical therapy, but in September 2017, Aetna began denying coverage on the ground that, pursuant to CPB #325, physical therapy was no longer "medically necessary." In response to Curtis's appeals, Aetna ultimately reversed its denials and approvedpayment of benefits for Curtis's physical therapy through April 2018, "thereby [according to Curtis] necessarily establishing that the physical therapy services ordered for . . . Curtis through April 2018 constituted covered benefits for eligible health services pursuant to the Yale Plan." Id. ¶ 28.³ The medical need and purpose of the physical therapy ordered for Curtis by his treating physicians prior to April 2018 did not abate or change in April 2018, and from April 2018 to the filing of the operative complaint, Curtis's treating physicians have continued to prescribe physical therapy as medically necessary to treat his ongoing balance, strength and mobility issues. Id. ¶ 29.

Aetna denied coverage for Curtis's physical therapy from April 2018 through November 17, 2019 as not medically necessary, notwithstanding his submission of documentation from his treating physicians attesting to the medical need and appropriateness of such therapy for him, in full satisfaction of the requirements set forth in the Yale Plan for establishing that the physical therapy is medically necessary. Id. ¶ 30. Curtis appealed Aetna's denial of post-April 2018 coverage for his physical therapy to Aetna and to a third party reviewing entity (as provided by the Yale Plan), but his appeals were denied on the ground that the physical therapy did not meet the requirements necessary to establish that the treatment was medically necessary as set forth in Aetna's internal policy, CPB #325. Id. ¶ 31. The medical necessity, purpose and likely effect of the physical therapy ordered for Curtis by his treating physicians has not abated or changed since April 2018. Id. ¶ 32. On January 14, 2020, Aetna advised Curtis that it had determined that the physical therapy services ordered by his physicians from November 18, 2019 through January 2, 2020 and ten additional sessions beginning on January 3, 2020 were eligible health servicesunder the Yale Plan. Id. ¶ 33. The medical necessity, purpose and likely effect of the physical therapy ordered for Curtis by his treating physicians after November 17, 2019 is identical to the medical necessity, purpose and likely effect of the physical therapy ordered for Curtis from April 2018 through November 17, 2019. Id. ¶ 34. Curtis alleges that the January 14, 2020 determination that his physical therapy services are eligible for benefits pursuant to the Yale Plan confirms that such services are covered, eligible health services under the Yale Plan as to which he is entitled to benefits. Id.

Aetna has denied Curtis coverage for physical therapy ordered by his treating physicians and certified by them as medically necessary on the ground that such therapy was not medically necessary pursuant to Aetna's CPB #325 because it would not "improve significantly" Curtis's physical condition within a specified duration, i.e., within one month of the start of service. Id. ¶¶ 25-26. Specifically, Curtis alleges that he has been denied covered benefits under the Yale Plan for physical therapy services from April 2018 through November 2019. Id. ¶ 35. Curtis has an ongoing need for physical therapy services. Id. ¶ 36.

B. The Putative Class

Curtis brings this action, pursuant to Fed. R. Civ. P. 23, on his own behalf and on behalf of the following Class and Sub-Class of persons similarly situated to him:

a. Class 1 is defined to include:

All participants or beneficiaries in the ERISA-governed group medical benefit Plans (both for self-funded employers or as a[n] insurer, directly or through its affiliates) as to which Aetna provides claims administration services.

b. Sub-Class 1a is defined to include:

All participants or beneficiaries in the ERISA-governed group medical benefit Plans (both for self-funded employers or as a[n] insurer, directly or through its affiliates) as to which Aetna provides claims administration services, who, during the relevant limitations period, have been denied benefits for therapy servicescovered by their Plans, as not medically necessary, based on requirements for establishing the therapy was medically necessary contained in Aetna's CPB #325, 243, 0032, 0214, 0250 and 0640 or other non-plan documents inconsistent with the Plans' definition of "medical necessary."

Id. ¶ 37.

The requirements for establishing that a medical service is "medically necessary" contained in the Plans are substantially identical. Id. ¶ 38. Aetna follows a uniform and systematic policy and practice of relying on the requirements set forth in the internal CPBs described above for establishing that medical services for physical therapy and other forms of rehabilitative therapy are medically necessary in determining whether claims for benefits for such services submitted by participants or beneficiaries pursuant to their Plans are medically necessary. Id. The CPBs uniformly contain requirements for establishing medical necessity that are not contained in the Plans, that impose additional requirements not contained in the Plans, and that misapply the plain meaning of the definition of medically necessary in the Plans, to the detriment of the Plans' members. Id.

C. The Yale Plan

The Yale Plan, which is...